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Arterial Hypertension: Evaluation and Management

  • Carissa M. Baker-Smith
  • Joseph FlynnEmail author
Living reference work entry
  • 7 Downloads

Abstract

High BP (BP) is one of the most common chronic conditions in youth. It is a known risk factor for cardiovascular disease (CVD) in adults. Based upon recent systematic analyses demonstrating that abnormal BP tracks from childhood into adulthood, high BP in youth may represent the earliest phase of adult hypertension (HTN). In this chapter, we summarize recent updates regarding the diag/nosis, management, and treatment of HTN in youth. We highlight some of the major changes incorporated into the 2017 Clinical Practice Guideline for Screening and Management of High BP in Children and Adolescents. We also briefly review topics related to the inpatient and intensive care unit related management of hospitalized children with high BP.

Keywords

Adolescent Ambulatory blood pressure monitoring American Academy of Pediatrics American College of Cardiology American Heart Association Antihypertensive medications Blood pressure measurement Children Chronic kidney disease Coarctation of the aorta Concentric hypertrophy Concentric remodeling Diastolic blood pressure Echocardiography Elevated blood pressure Essential hypertension High blood pressure Hypertension Hypertensive emergency Hypertensive urgency Left ventricular hypertrophy Manual blood pressure Oscillometric blood pressure Renal artery stenosis Secondary hypertension Systolic blood pressure Turner syndrome White coat hypertension Williams syndrome 

Introduction

It is estimated that at least 3–4% of all children are hypertensive and another 3–4% have elevated blood pressure (BP) [1]. Data suggests that the prevalence of hypertension (HTN) has increased in parallel with the rising prevalence of childhood obesity [2, 3]. Potential causes of HTN in youth include: use of medications that increase BP, chronic kidney disease (CKD), coarctation of the aorta, genetic conditions that impact salt regulation, solid organ transplantation, and endocrine-related disorders. However, the majority of hypertensive children and adolescents have no identifiable cause [4]. Risk factors for HTN in youth with suspected primary HTN include a family history of HTN, intake of a high salt diet, obesity, and sleep disordered breathing (SDB).

Recommendations regarding the diagnosis, management, and treatment of high BP in youth were recently updated with the publication of the 2017 Clinical Practice Guideline for Screening and Management of High BP in Children and Adolescents. This chapter summarizes current knowledge regarding the diagnosis and management of high BP in youth.

Evaluation of the Child or Adolescent with Elevated BP

Definitions of HTN

Evaluation of the hypertensive child or adolescent begins with use of proper BP measurement technique: a resting patient, an appropriate sized BP cuff and confirmation of abnormal BP via manual BP assessment [5]. Two or more measurements per visit (if the first is abnormal), over several visits, are required to confirm elevated BP as many children may have falsely elevated BP readings during a first or second assessment but a normal BP reading during a subsequent assessment [6]. A thorough history and physical exam followed by focused laboratory testing and imaging studies are necessary to distinguish primary from secondary causes of HTN. Secondary causes of HTN, in particular renal related causes, are common among youth under 6 years of age [4] while primary hypertension is more common among adolescents [5].

Definitions of HTN

In the absence of long-term data linking childhood BP to adult onset cardiovascular sequelae of HTN, such as myocardial infarction and stroke, the 2004 National High BP Education Program Working Group on High BP in Children and Adolescents defined HTN in youth solely upon BP percentiles. While maintaining a percentile-based definition of HBP for youth under 13 years of age, the 2017 CPG also adopted single cut-point definitions of HTN for adolescents ≥13 years of age that align with updated American Heart Association (AHA)/American College of Cardiology (ACC) definitions of HBP [7]. See Table 1 for a summary of the new definitions.
Table 1

Updated Definitions of Blood Pressure (BP) Categories and Stages (adapted from 2017 AAP CPG [5])

Normal BP: BP <90th percentile for age, sex, and height; or <120/<80 mmHg for adolescents ≥13 years old;

Elevated BP: BP reading ≥90th percentile and <95th percentile for age, sex, and height; or 120–129/<80 mmHg for adolescents ≥13 years old;

Hypertension: BP >95th percentile for age, sex, and height; or ≥130/80 mmHg for adolescents ≥13 years old.

Stage 1 hypertension: BP >95th percentile for age, sex, and height up to the 95th percentile +11 mmHg; or 130–139/80–89 mmHg for adolescents ≥13 years of age; and

Stage 2 hypertension: BP ≥95th percentile +12 mmHg for age, sex, and height; or >140/90 mmHg for adolescents ≥13 years of age.

Diagnosis: Recognition and Confirmation of Elevated BP

Initial BP assessments, especially if performed using an automated device, may be abnormal [8]. Initial abnormal BP readings should be repeated as current estimates suggest that only a small fraction (e.g., 4% for Stage 1 and 7% for Stage 2) of children with an abnormal initial BP measurement will have repeated BPs that are abnormal [9]. The degree of variability in BP measurement, when repeated, may vary by age [10]. Furthermore, there may be an accommodation effect such that at least ½ of all children found to have BP measurements during a first outpatient encounter that exceed established cutoff values will have more normal BP measurements during a subsequent encounter [6]. It is estimated that 2% of youth with an initial visit indicating Stage 1 HTN, and 11% of youth with an initial visit indicating Stage II HTN, will continue to have high BP during follow-up visits [6].

Failure to correctly identify measured BPs as abnormal have likely contributed to a falsely low estimated prevalence of HTN in youth. According to recent published data, only 26% of children are correctly identified as having high BP [1]. This is perhaps related to the time-consuming and multistep process of referencing normative BP tables in the office and recognition of an HBP when abnormal BP is defined as a value below 120/80 mmHg. The 2017 CPG introduced use of a validated, simplified BP table to assist with recognition of abnormal BP [11]. The simplified table includes a single BP value for each age and gender. This value represents the 90th BP percentile for the fifth height percentile for girls and boys, separately. If the BP is abnormal, according to the simplified table, then repeat assessment is recommended with confirmation via manual BP measurement and use of the more detailed BP tables (2017 CPG) for diagnosis and staging (Tables 2 and 3).
Table 2

BP Levels for Boys by Age and Height Percentile (permission required)

Age (y)

BP Percentile

SBP (mmHg)

DBP (mmHg)

Height Percentile or Measured Height

Height Percentile or Measured Height

5%

10%

25%

50%

75%

90%

95%

5%

10%

25%

50%

75%

90%

95%

1

Height (in)

30.4

30.8

31.6

32.4

33.3

34.1

34.6

30.4

30.8

31.6

32.4

33.3

34.1

34.6

Height (cm)

77.2

78.3

80.2

82.4

84.6

86.7

87.9

77.2

78.3

80.2

82.4

84.6

86.7

87.9

50th

85

85

86

86

87

88

88

40

40

40

41

41

42

42

90th

98

99

99

100

100

101

101

52

52

53

53

54

54

54

95th

102

102

103

103

104

105

105

54

54

55

55

56

57

57

95th + 12 mmHg

114

114

115

115

116

117

117

66

66

67

67

68

69

69

2

Height (in)

33.9

34.4

35.3

36.3

37.3

38.2

38.8

33.9

34.4

35.3

36.3

37.3

38.2

38.8

Height (cm)

86.1

87.4

89.6

92.1

94.7

97.1

98.5

86.1

87.4

89.6

92.1

94.7

97.1

98.5

50th

87

87

88

89

89

90

91

43

43

44

44

45

46

46

90th

100

100

101

102

103

103

104

55

55

56

56

57

58

58

95th

104

105

105

106

107

107

108

57

58

58

59

60

61

61

95th + 12 mmHg

116

117

117

118

119

119

120

69

70

70

71

72

73

73

3

Height (in)

36.4

37

37.9

39

40.1

41.1

41.7

36.4

37

37.9

39

40.1

41.1

41.7

Height (cm)

92.5

93.9

96.3

99

101.8

104.3

105.8

92.5

93.9

96.3

99

101.8

104.3

105.8

50th

88

89

89

90

91

92

92

45

46

46

47

48

49

49

90th

101

102

102

103

104

105

105

58

58

59

59

60

61

61

95th

106

106

107

107

108

109

109

60

61

61

62

63

64

64

95th + 12 mmHg

118

118

119

119

120

121

121

72

73

73

74

75

76

76

4

Height (in)

38.8

39.4

40.5

41.7

42.9

43.9

44.5

38.8

39.4

40.5

41.7

42.9

43.9

44.5

Height (cm)

98.5

100.2

102.9

105.9

108.9

111.5

113.2

98.5

100.2

102.9

105.9

108.9

111.5

113.2

50th

90

90

91

92

93

94

94

48

49

49

50

51

52

52

90th

102

103

104

105

105

106

107

60

61

62

62

63

64

64

95th

107

107

108

108

109

110

110

63

64

65

66

67

67

68

95th + 12 mmHg

119

119

120

120

121

122

122

75

76

77

78

79

79

80

5

Height (in)

41.1

41.8

43.0

44.3

45.5

46.7

47.4

41.1

41.8

43.0

44.3

45.5

46.7

47.4

Height (cm)

104.4

106.2

109.1

112.4

115.7

118.6

120.3

104.4

106.2

109.1

112.4

115.7

118.6

120.3

50th

91

92

93

94

95

96

96

51

51

52

53

54

55

55

90th

103

104

105

106

107

108

108

63

64

65

65

66

67

67

95th

107

108

109

109

110

111

112

66

67

68

69

70

70

71

95th + 12 mmHg

119

120

121

121

122

123

124

78

79

80

81

82

82

83

6

Height (in)

43.4

44.2

45.4

46.8

48.2

49.4

50.2

43.4

44.2

45.4

46.8

48.2

49.4

50.2

Height (cm)

110.3

112.2

115.3

118.9

122.4

125.6

127.5

110.3

112.2

115.3

118.9

122.4

125.6

127.5

50th

93

93

94

95

96

97

98

54

54

55

56

57

57

58

90th

105

105

106

107

109

110

110

66

66

67

68

68

69

69

95th

108

109

110

111

112

113

114

69

70

70

71

72

72

73

95th + 12 mmHg

120

121

122

123

124

125

126

81

82

82

83

84

84

85

7

Height (in)

45.7

46.5

47.8

49.3

50.8

52.1

52.9

45.7

46.5

47.8

49.3

50.8

52.1

52.9

Height (cm)

116.1

118

121.4

125.1

128.9

132.4

134.5

116.1

118

121.4

125.1

128.9

132.4

134.5

50th

94

94

95

97

98

98

99

56

56

57

58

58

59

59

90th

106

107

108

109

110

111

111

68

68

69

70

70

71

71

95th

110

110

111

112

114

115

116

71

71

72

73

73

74

74

95th + 12 mmHg

122

122

123

124

126

127

128

83

83

84

85

85

86

86

8

Height (in)

47.8

48.6

50

51.6

53.2

54.6

55.5

47.8

48.6

50

51.6

53.2

54.6

55.5

Height (cm)

121.4

123.5

127

131

135.1

138.8

141

121.4

123.5

127

131

135.1

138.8

141

50th

95

96

97

98

99

99

100

57

57

58

59

59

60

60

90th

107

108

109

110

111

112

112

69

70

70

71

72

72

73

95th

111

112

112

114

115

116

117

72

73

73

74

75

75

75

95th + 12 mmHg

123

124

124

126

127

128

129

84

85

85

86

87

87

87

9

Height (in)

49.6

50.5

52

53.7

55.4

56.9

57.9

49.6

50.5

52

53.7

55.4

56.9

57.9

Height (cm)

126

128.3

132.1

136.3

140.7

144.7

147.1

126

128.3

132.1

136.3

140.7

144.7

147.1

50th

96

97

98

99

100

101

101

57

58

59

60

61

62

62

90th

107

108

109

110

112

113

114

70

71

72

73

74

74

74

95th

112

112

113

115

116

118

119

74

74

75

76

76

77

77

95th + 12 mmHg

124

124

125

127

128

130

131

86

86

87

88

88

89

89

10

Height (in)

51.3

52.2

53.8

55.6

57.4

59.1

60.1

51.3

52.2

53.8

55.6

57.4

59.1

60.1

Height (cm)

130.2

132.7

136.7

141.3

145.9

150.1

152.7

130.2

132.7

136.7

141.3

145.9

150.1

152.7

50th

97

98

99

100

101

102

103

59

60

61

62

63

63

64

90th

108

109

111

112

113

115

116

72

73

74

74

75

75

76

95th

112

113

114

116

118

120

121

76

76

77

77

78

78

78

95th + 12 mmHg

124

125

126

128

130

132

133

88

88

89

89

90

90

90

11

Height (in)

53

54

55.7

57.6

59.6

61.3

62.4

53

54

55.7

57.6

59.6

61.3

62.4

Height (cm)

134.7

137.3

141.5

146.4

151.3

155.8

158.6

134.7

137.7

141.5

146.4

151.3

155.8

158.6

50th

99

99

101

102

103

104

106

61

61

62

63

63

63

63

90th

110

111

112

114

116

117

118

74

74

75

75

75

76

76

95th

114

114

116

118

120

123

124

77

78

78

78

78

78

78

95th + 12 mmHg

126

126

128

130

132

135

136

89

90

90

90

90

90

90

12

Height (in)

55.2

56.3

58.1

60.1

62.2

64

65.2

55.2

56.3

58.1

60.1

62.2

64

65.2

Height (cm)

140.3

143

147.5

152.7

157.9

162.6

165.5

140.3

143

147.5

152.7

157.9

162.6

165.5

50th

101

101

102

104

106

108

109

61

62

62

62

62

63

63

90th

113

114

115

117

119

121

122

75

75

75

75

75

76

76

95th

116

117

118

121

124

126

128

78

78

78

78

78

79

79

95th + 12 mmHg

128

129

130

133

136

138

140

90

90

90

90

90

91

91

13

Height (in)

57.9

59.1

61

63.1

65.2

67.1

68.3

57.9

59.1

61

63.1

65.2

67.1

68.3

Height (cm)

147

150

154.9

160.3

165.7

170.5

173.4

147

150

154.9

160.3

165.7

170.5

173.4

50th

103

104

105

108

110

111

112

61

60

61

62

63

64

65

90th

115

116

118

121

124

126

126

74

74

74

75

76

77

77

95th

119

120

122

125

128

130

131

78

78

78

78

80

81

81

95th + 12 mmHg

131

132

134

137

140

142

143

90

90

90

90

92

93

93

Table 3

BP Levels for Girls by Age and Height Percentile (permission required)

Age (y)

BP Percentile

SBP (mmHg)

DBP (mmHg)

Height Percentile or Measured Height

Height Percentile or Measured Height

5%

10%

25%

50%

75%

90%

95%

5%

10%

25%

50%

75%

90%

95%

1

Height (in)

29.7

30.2

30.9

31.8

32.7

33.4

33.9

29.7

30.2

30.9

31.8

32.7

33.4

33.9

Height (cm)

75.4

76.6

78.6

80.8

83

84.9

86.1

75.4

76.6

78.6

80.8

83

84.9

86.1

50th

84

85

86

86

87

88

88

41

42

42

43

44

45

46

90th

98

99

99

100

101

102

102

54

55

56

56

57

58

58

95th

101

102

102

103

104

105

105

59

59

60

60

61

62

62

95th + 12 mmHg

113

114

114

115

116

117

117

71

71

72

72

73

74

74

2

Height (in)

33.4

34

34.9

35.9

36.9

37.8

38.4

33.4

34

34.9

35.9

36.9

37.8

38.4

Height (cm)

84.9

86.3

88.6

91.1

93.7

96

94.4

84.9

86.3

88.6

91.1

93.7

96

97.4

50th

87

87

88

89

90

91

91

45

46

47

48

49

50

51

90th

101

101

102

103

104

105

106

58

58

59

60

61

62

62

95th

104

105

106

106

107

108

109

62

63

63

64

65

66

66

95th + 12 mmHg

116

117

118

118

119

120

121

74

75

75

76

77

78

78

3

Height (in)

35.8

36.4

37.3

38.4

39.6

40.6

41.2

35.8

36.4

37.3

38.4

39.6

40.6

41.2

Height (cm)

91

92.4

94.9

97.6

100.5

103.1

104.6

91

92.4

94.9

97.6

100.5

103.1

104.6

50th

88

89

89

90

91

92

93

48

48

49

50

51

53

53

90th

102

103

104

104

105

106

107

60

61

61

62

63

64

65

95th

106

106

107

108

109

110

110

64

65

65

66

67

68

69

95th + 12 mmHg

118

118

119

120

121

122

122

76

77

77

78

79

80

81

4

Height (in)

38.3

38.9

39.9

41.1

42.4

43.5

44.2

38.3

38.9

39.9

41.1

42.4

43.5

44.2

Height (cm)

97.2

98.8

101.4

104.5

107.6

110.5

112.2

97.2

98.8

101.4

104.5

107.6

110.5

112.2

50th

89

90

91

92

93

94

94

50

51

51

53

54

55

55

90th

103

104

105

106

107

108

108

62

63

64

65

66

67

67

95th

107

108

109

109

110

111

112

66

67

68

69

70

70

71

95th + 12 mmHg

119

120

121

121

122

123

124

78

79

80

81

82

82

83

5

Height (in)

40.8

41.5

42.6

43.9

45.2

46.5

47.3

40.8

41.5

42.6

43.9

45.2

46.5

47.3

Height (cm)

103.6

105.3

108.2

111.5

114.9

118.1

120

103.6

105.3

108.2

111.5

114.9

118.1

120

50th

90

91

92

93

94

95

96

52

52

53

55

56

57

57

90th

104

105

106

107

108

109

110

64

65

66

67

68

69

70

95th

108

109

109

110

111

112

113

68

69

70

71

72

73

73

95th + 12 mmHg

120

121

121

122

123

124

125

80

81

82

83

84

85

85

6

Height (in)

43.3

44

45.2

46.6

48.1

49.4

50.3

43.3

44

45.2

46.6

48.1

49.4

50.3

Height (cm)

110

111.8

114.9

118.4

122.1

125.6

127.7

110

111.8

114.9

118.4

122.1

125.6

127.7

50th

92

92

93

94

96

97

97

54

54

55

56

57

58

59

90th

105

106

107

108

109

110

111

67

67

68

69

70

71

71

95th

109

109

110

111

112

113

114

70

71

72

72

73

74

74

95th + 12 mmHg

121

121

122

123

124

125

126

82

83

84

84

85

86

86

7

Height (in)

45.6

46.4

47.7

49.2

50.7

52.1

53

45.6

46.4

47.7

49.2

50.7

52.1

53

Height (cm)

115.9

117.8

121.1

124.9

128.8

132.5

134.7

115.9

117.8

121.1

124.9

128.8

132.5

134.7

50th

92

93

94

95

97

98

99

55

55

56

57

58

59

60

90th

106

106

107

109

110

111

112

68

68

69

70

71

72

72

95th

109

110

111

112

113

114

115

72

72

73

73

74

74

75

95th + 12 mmHg

121

122

123

124

125

126

127

84

84

85

85

86

86

87

8

Height (in)

47.6

48.4

49.8

51.4

53

54.5

55.5

47.6

48.4

49.8

51.4

53

54.5

55.5

Height (cm)

121

123

126.5

130.6

134.7

138.5

140.9

121

123

126.5

130.6

134.7

138.5

140.9

50th

93

94

95

97

98

99

100

56

56

57

59

60

61

61

90th

107

107

108

110

111

112

113

69

70

71

72

72

73

73

95th

110

111

112

113

115

116

117

72

73

74

74

75

75

75

95th + 12 mmHg

122

123

124

125

127

128

129

84

85

86

86

87

87

87

9

Height (in)

49.3

50.2

51.7

53.4

55.1

56.7

57.7

49.3

50.2

51.7

53.4

55.1

56.7

57.7

Height (cm)

125.3

127.6

131.3

135.6

140.1

144.1

146.6

125.3

127.6

131.3

135.6

140.1

144.1

146.6

50th

95

95

97

98

99

100

101

57

58

59

60

60

61

61

90th

108

108

109

111

112

113

114

71

71

72

73

73

73

73

95th

112

112

113

114

116

117

118

74

74

75

75

75

75

75

95th + 12 mmHg

124

124

125

126

128

129

130

86

86

87

87

87

87

87

10

Height (in)

51.1

52

53.7

55.5

57.4

59.1

60.2

51.1

52

53.7

55.5

57.4

59.1

60.2

Height (cm)

129.7

132.2

136.3

141

145.8

150.2

152.8

129.7

132.2

136.3

141

145.8

150.2

152.8

50th

96

97

98

99

101

102

103

58

59

59

60

61

61

62

90th

109

110

111

112

113

115

116

72

73

73

73

73

73

73

95th

113

114

114

116

117

119

120

75

75

76

76

76

76

76

95th + 12 mmHg

125

126

126

128

129

131

132

87

87

88

88

88

88

88

11

Height (in)

53.4

54.5

56.2

58.2

60.2

61.9

63

53.4

54.5

56.2

58.2

60.2

61.9

63

Height (cm)

135.6

138.3

142.8

147.8

152.8

157.3

160

135.6

138.3

142.8

147.8

152.8

157.3

160

50th

98

99

101

102

104

105

106

60

60

60

61

62

63

64

90th

111

112

113

114

116

118

120

74

74

74

74

74

75

75

95th

115

116

117

118

120

123

124

76

77

77

77

77

77

77

95th + 12 mmHg

127

128

129

130

132

135

136

88

89

89

89

89

89

89

12

Height (in)

56.2

57.3

59

60.9

62.8

64.5

65.5

56.2

57.3

59

60.9

62.8

64.5

65.5

Height (cm)

142.8

145.5

149.9

154.8

159.6

163.8

166.4

142.8

145.5

149.9

154.8

159.6

163.8

166.4

50th

102

102

104

105

107

108

108

61

61

61

62

64

65

65

90th

114

115

116

118

120

122

122

75

75

75

75

76

76

76

95th

118

119

120

122

124

125

126

78

78

78

78

79

79

79

95th + 12 mmHg

130

131

132

134

136

137

138

90

90

90

90

91

91

91

13

Height (in)

58.3

59.3

60.9

62.7

64.5

66.1

67

58.3

59.3

60.9

62.7

64.5

66.1

67

Height (cm)

148.1

150.6

154.7

159.2

163.7

167.8

170.2

148.1

150.6

154.7

159.2

163.7

167.8

170.2

50th

104

105

106

107

108

108

109

62

62

63

64

65

65

66

90th

116

117

119

121

122

123

123

75

75

75

76

76

76

76

95th

121

122

123

124

126

126

127

79

79

79

79

80

80

81

95th + 12 mmHg

133

134

135

136

138

138

139

91

91

91

91

92

92

93

The importance of repeat BP assessment cannot be overstated [12]. The physical state of the child impacts the BP, as does the presence or absence of other comorbidities, such as obesity. BP in childhood is more labile than in adults. One large cohort study found that only 56% of children fell into the same BP category with repeated measure [13]. Age may also play a role in the degree of variability in BP measurement where older children exhibit less variability in measurement [9] (Table 4).
Table 4

Patient Evaluation and Management According to Blood Pressure (BP) Level

BP category (see Table 3)

BP Screening Schedule

Lifestyle Counseling (Weight, Nutrition)

Check Upper and Lower Extremity BP

ABPM

Diagnostic Evaluation

Initiate Treatment

Consider Sub-specialty Referral

Normal

Annual

X

     

Elevated BP

Initial measurement

X

     

Second measurement: Repeat in 6 months

X

X

    

Third measurement; Repeat in 6 months

X

 

X

X

 

X

Stage 1 HTN

Initial measurement

X

     

Second measurement: Repeat in 1–2 weeks

X

X

    

Third measurement: Repeat in 3 months

X

 

X

X

X

X

Stage 2 HTN

Initial measurement

X

X

    

Second measurement: Repeat/refer to specialty care within 1 week

X

 

X

X

X

X

Legend: HTN hypertension, ABPM ambulatory blood pressure monitoring

Attention also needs to be paid to the size of the cuff used for measuring BP. The bladder cuff length should encompass 80–100% of the arm circumference and/or the width of the BP cuff encompasses 40% of the arm circumference [14]. If the cuff is too small, then the reading may be falsely elevated. Larger children may require use of a large adult cuff or even a thigh cuff.

Ideally, ambulatory BP monitoring (ABPM) is performed to confirm the diagnosis of HTN. ABPM is mostly used to distinguish essential HTN from white coat HTN but may also be used for diagnosing masked HTN (MH). ABPM, along with office DBP, may be helpful in distinguishing primary from secondary causes of HTN where elevated DBP and abnormal nocturnal ABPM measurements are more likely to be associated with secondary HTN [15]. Following initiation of antihypertensive therapy, ABPM be used to assess for adequacy of control of the BP [16] (Table 5).
Table 5

Classification of Blood Pressure (BP) Patterns According to Office and Ambulatory BP Values

BP Pattern

Office BP

Ambulatory BP

Normotensive

Normal

Normal

White coat HTN

Elevated

Normal

Ambulatory HTN

Elevated

Elevated

Masked HTN

Normal

Elevated

Legend: HTN hypertension

It is important to note that at least 7% of children who have not yet been started on antihypertensive therapy have normal in office BP measurements but abnormal out of office measurements, also known as masked HTN (MH) [17]. MH is more common among persons with a history of aortic coarctation [18], CKD [19], renal transplantation [20], and cardiac transplantation [21]. Use of ABPM is required in order to make the diagnosis of MH, and a high index of suspicion should be maintained when considering the possibility of MH.

Diagnosis: Differential Diagnosis

Before embarking on an extensive diagnostic work-up, one should try to develop a potential differential diagnosis for the child’s HTN. Young children are more likely to have secondary HTN, whereas adolescents are more likely to have primary HTN (see Table 6).
Table 6

Differential Diagnosis of Secondary Hypertension (HTN) in Children and Adolescents

Renal

Endocrine

 Obstructive lesions (UPJ, UVJ)

 Cushing’s syndrome

 Glomerulonephritis (acute or chronic)

 Primary aldosteronism

 Other acquired renal parenchymal disease (pyelonephritis, reflux, nephropathy, infarction)

 Hyperparathyroidism

 

 Congenital adrenal hyperplasia

 

 Hyperthyroidism

Renovascular disease

Genetic

 Intrinsic: Fibromuscular hyperplasia, arterial or venous thrombosis

 Turner’s syndrome

 Extrinsic: Compression

 Williams syndrome

 

 Neurofibromatosis

 Tuberous sclerosis

Congenital defects

Monogenic

 Hypoplasia/dysplasia, autosomal

 Liddle syndrome, AME, GRA

 Dominant or recessive PCKD

 

Hemolytic uremic syndrome

 

Vascular

Neoplastic

 Aortic coarctation

 Renal tumors (renal cell carcinoma, Wilms tumor)

 Mi-aortic syndrome

 Pheochromocytoma

 Vasculitis (Takayasu’s, polyarteritis nodosa)

 Neuroblastoma

Neurologic

Miscellaneous

 Increased intracranial pressure

 Drug-induced

 Guillain-Barre syndrome

 Stress

 Cervical and leg traction

 Organ transplantation

 Pain

 

Legend: AME apparent mineralocorticoid excess, GRA glucocorticoid-remediable aldosteronism, PCKD polycystic kidney disease, UPJ ureteropelvic junction, UVJ ureterovesical junction

Among US children adolescents found to have high BP, primary HTN is the most common cause of HTN [22, 23]. A positive family history of HTN and obesity increase the likelihood of primary HTN as the cause. Offspring of hypertensive parents have been found to have higher BPs and an increased prevalence of other cardiovascular disease (CVD) risk factors [24]. The prevalence of a positive family history of HTN in children and adolescents with primary HTN has been reported to be greater than 80% [21]. Thus, a family history of HTN (or of other CVD such as stroke) increases the likelihood of a diagnosis of primary HTN, especially when the results of initial diagnostic studies are normal [22]. Obesity is more common among pediatric patients with primary HTN than among those with secondary HTN and is associated with an earlier age of onset of HTN, independent of family history [25].

Diagnosis: History and Physical Examination

Evaluation of the hypertensive child or adolescent should begin with a complete medical history and physical examination. Children with HTN may not have symptoms. However, symptoms of headache, dizziness, and diplopia have been reported. Symptoms associated with comorbidities of HTN may be present, including symptoms common to diabetes, sleep disordered breathing (SDB), renal disease, heart disease, and diseases affecting other organ systems such as the endocrine system (see Table 7). The past medical history should include questions about recent as well as chronic illnesses, prior hospitalizations or episodes of trauma, recurrent urinary tract infections, or unexplained fevers, as well as the neonatal history. Family history of HTN, diabetes, renal disease, and other cardiovascular disease (hyperlipidemia, myocardial infarction at an early age) should be elicited. Finally, it is important to ask about over-the-counter, prescription, and illicit drug use, as many commonly used substances can either cause or exacerbate HTN (see Table 8).
Table 7

History and Physical Examination Findings Suggestive of Secondary HTN

Present in History

Suggests

Known UTI/UTI symptoms

Reflux nephropathy

Joint pains, rash, fever

Vasculitis, SLE

Acute onset of gross hematuria

Glomerulonephritis, renal thrombosis

Renal trauma

Renal infarct, RAS

Abdominal radiation

Radiation nephritis, RAS

Renal transplant

Transplant RAS

Precocious puberty

Adrenal disorder

Muscle cramping, constipation

Hyperaldosteronism

Excessive sweating, headache, pallor, and/or flushing

Pheochromocytoma

Known illicit drug use

Drug-induced hypertension

Present on examination

Suggests

BP > 140/100 mmHg at any age

Secondary hypertension

Leg BP < arm BP

Aortic coarctation

Poor growth, pallor

Chronic renal disease

Turner syndrome

Aortic coarctation

Café au lait spots

Renal artery stenosis

Delayed leg pulses

Aortic coarctation

Precocious puberty

Adrenal disorder

Bruits over upper abdomen

Renal artery stenosis

Edema

Renal disease

Excessive sweating

Pheochromocytoma

Excessive pigmentation

Adrenal disorder

Striae in a male

Drug-induced HTN

Legend: UTI urinary tract infection, BP blood pressure, SLE systemic lupus erythematosus, RAS renal artery stenosis, HTN hypertension

Table 8

Potential Substance Related Causes of Elevated BP

Prescription medications

Nonprescription medications

Others

Calcineurin inhibitors (cyclosporine, tacrolimus)

Caffeine

Cocaine

COX-2 inhibitors (celecoxib, others)

Ephedrine

DHEA (dehydroepiandrosterone)

Erythropoietin

Nonsteroidal anti-inflammatory drugs

Ethanol

Glucocorticoids

Pseudoephedrine

Heavy metals (lead, mercury)

Migraine medications (ergotamine, sumatriptan)

 

Herbal preparations (Ephedra, Glycyrrhiza)

Oral contraceptives

 

MDMA (“Ecstasy”)

Phenylpropanolamine

 

Tobacco

Pseudoephedrine

  

Stimulant medications (dexedrine, methylphenidate, amphetamine derivatives)

  

Tricyclic antidepressants

  

Physical examination should begin with measurement of the child’s weight and height so that body mass index (BMI) can be calculated. Among children with elevated BMI, there is a higher likelihood of abnormal BP [26]. For children under 13 years, age, gender, and height are used to determine the BP percentile. BP should be obtained in the right upper extremity, in the seated position. The BP may be obtained via oscillometric measurement initially; however, if abnormal, should be repeated manually. If the BP is at least Stage 2, then it should be repeated with a measurement in the upper and lower extremity. Repeat measurements for elevated BP and Stage 1 should be repeated in the UE and LE to rule out coarctation. As with the history, the rest of the physical examination should focus on uncovering signs of specific underlying disorders that may be causing the child’s HTN (see Table 7). In obese adolescents, there may be signs of insulin resistance such as acanthosis nigricans, or in females, findings suggestive of polycystic ovary syndrome (PCOS), such as hirsutism. The physical examination may also provide clues as to the severity/chronicity of the patient’s HTN, such as left ventricular hypertrophy (LVH) or hypertensive retinopathy.

Diagnosis: Laboratory Testing and Imaging

Patients with confirmed HTN should undergo a tailored diagnostic evaluation, to confirm or exclude secondary causes, and should also be assessed for the presence of other cardiovascular risk factors. It is typical to obtain a basic set of screening studies in all patients, including a urinalysis, serum chemistries (electrolytes, BUN/creatinine), fasting lipid panel, and fasting glucose or hemoglobin A1c (HgbA1c) [5]. Children with signs or symptoms consistent with thyroid disease should undergo screening thyroid testing. Given the reported association between obstructive sleep apnea (OSA) and elevated BP, children with a history of snoring, daytime sleepiness or difficulty focusing should undergo a sleep study. For children with a growth delay or abnormal renal function, a complete blood count should be performed.

Recent reports confirm the frequent presence of dyslipidemia in children and adolescents with high BP, especially among those who are obese [5]. The typical pattern is normal to slightly elevated total cholesterol with low HDL cholesterol and elevated triglyceride (TG) levels. This pattern is similar to the dyslipidemia that occurs in type 2 DM and likely reflects underlying insulin resistance, even in nonobese hypertensives. Obese adolescents with HTN may also have impaired glucose tolerance which, in conjunction with elevated BP and dyslipidemia, would be consistent with the metabolic syndrome. Identification of multiple cardiovascular risk factors in children or adolescents should be considered indicative of an increased risk of premature CVD and would call for more intensive management.

Given the high likelihood of primary HTN, a renal ultrasound, which is routinely obtained in younger children (<6 years old) with HTN, may be omitted in some older school-aged children and adolescents with Stage 1 HTN if the following conditions are met:
  • Normal screening studies

  • Presence of typical features of primary HTN, including obesity, a positive family history, and isolated systolic HTN

Those with stage 2 HTN, with abnormal screening laboratory studies, or with diastolic or sleep HTN on ABPM should have a renal ultrasound. Additional imaging studies, including renal angiography, should be obtained only in selected children and adolescents based upon the results of the history, physical examination, and initial imaging studies.

Diagnosis: Assessment for Hypertensive Target-Organ Damage

Elevated BP in youth is not only a predictor of systemic HTN during adulthood [27], but HTN in youth is associated with the development of target organ damage (TOD), including changes in the kidney, eye, and increased left ventricular mass [28]. It is estimated that 40% of children with high BP (HBP) have left ventricular hypertrophy (LVH). However, neither the severity of casual BP elevation nor the presence of abnormal ambulatory BP at initial diagnosis is predictive of LVH [29].

Echocardiography is required to determine the presence or absence of LVH and expensive, less readily available imaging modalities, such as MRI are not routinely recommended. In the 2017 CPG, a set definition of LVH is provided, and the performance of an echocardiogram to identify LVH as an indication for the initiation of antihypertensive therapy is no longer recommended. Given that there are no widely agreed upon definitions of LVH, based upon expert opinion, the 2017 CPG defines LVH as LVM ≥51 g/m2.7 for youth 8 years of age or older or LVM >115 g/m2 for boys and >95 g/m2 for girls for youth under 8 years of age. A cutoff value for the LVMI of 51 g/m2.7 was selected as it represents the 97.5th percentile for LV mass in adults [30]. It was also selected because LVMI of 51 g/m2.7 has been shown to be associated with a 4.1-fold risk of cardiovascular morbidity in adults with HTN [31].

Prior to the onset of LVH, changes in left ventricular (LV) geometry may occur. Concentric remodeling may precede the development of concentric hypertrophy where concentric remodeling is defined as increased relative wall thickness (RWT) but normal left ventricular mass (LVM). Eccentric hypertrophy may also occur and has been defined as increased LVMI and a normal RWT.

Given the low sensitivity of the electrocardiogram for identifying LVH, performance of an ECG is not recommended for screening for LVH in the 2017 CPG [32]. It was also not recommended in the fourth report [12].

Approach to Therapy

Treatment: Non-pharmacologic Therapies

Treatment of HTN in children and adolescents is still largely empiric, because no long-term studies of either dietary intervention or drug therapy have been conducted. The 2017 CPG recommends non-pharmacologic intervention as the initial treatment for elevated BP and Stage 1 HTN, while pharmacologic intervention, in addition to non-pharmacologic intervention, has been recommended as treatment for cases for confirmed Stage 2 HTN [5].

Weight loss, exercise, and dietary modifications have all been shown to reduce BP in children and adolescents and are, therefore, considered primary treatment. Studies in obese children have shown that even modest reductions in weight can have a significant impact on BP. Not to mention that reductions in weight can have a significant impact on other cardiovascular disease related risk factors, including dyslipidemia and obstructive sleep apnea.

Aerobic forms of exercise are generally recommended in the management of HTN in the young. It is recommended, however, based upon current AHA/ACC guidelines (adopted by the AAP), that youth with Stage 2 HTN not participate in competitive sports until their BPs are in the Stage 1 range. Youth with Stage 1 HTN and no evidence of TOD may participate in all competitive sports [33], while youth with Stage 1 HTN and TOD should undergo careful evaluation prior to return or prior to being allowed to participate in competitive sports [34].

Nutrients that have been proposed as having a potential positive impact on BP include calcium and potassium. In addition, a reduction in salt intake has been shown to be beneficial [35]. These dietary constituents are emphasized in the Dietary Approaches to Stopping HTN (DASH) diet (www.dashdiet.org), which was endorsed for use in children and adolescents in the 2017 CPG.

Treatment: Antihypertensive Medications

The most commonly used classes of antihypertensive agents employed for the treatment of HTN in youth include calcium channel blockers (CCB), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and diuretics [36]. Although the 2017 CPG endorsed the use of diuretics as initial therapy, in practice they are likely most effectively employed as combination therapy alongside use of one of the other aforementioned classes of antihypertensive medications (Table 9).
Table 9

Suggested Doses of Antihypertensive Medications for Use in Children

Class

Drug

Starting Dose

Interval

Maximum Dosea

ARAs

Eplerenone

25 mg/day

QD – BID

100 mg/day

 

Spironolactoneb

1 mg/kg/day

QD – BID

3.3 mg/kg/day up to 100 mg/day

ARBs

Candesartanb

1–6 years: 0.2 mg/kg/day (up to 4 mg/day)

6–17 years: <50 kg 4–8 mg QD

>50 kg 8–16 mg QD

QD

1–6 years: 0.4 mg/kg/day (up to 16 mg/day)

6–17 years: <50 kg 16 mg daily

     >50 kg 32 mg daily

 

Losartanb

0.7 mg/kg/day (up to 50 mg QD)

QD

1.4 mg/kg/day (up to 100 mg QD)

 

Olmesartanb

20–35 kg: 10 mg QD

≥35 kg: 20 mg QD

QD

20–35 kg: 20 mg QD

≥35 kg: 40 mg QD

 

Valsartanb

6–17 years: 1.3 mg/kg/day (up to 40 mg QD)

QD

6–17 years: 2.7 mg/kg/day (up to 160 mg QD)

ACE inhibitors

Benzeprilb

0.2 mg/kg/day (up to 10 mg/day)

QD

0.6 mg/kg/day (up to 40 mg/day)

 

Captoprilb

Infants: 0.05 mg/kg/dose

Children: 0.5 mg/kg/dose

BID – TID

6 mg/kg/day

6 mg/kg/day (up to 450 mg/day)

 

Enalaprilc

0.08 mg/kg/day (up to 5 mg/day)

QD – BID

0.6 mg/kg/day (up to 40 mg/day)

 

Fosinopril

0.1 mg/kg/day (up to 5 mg/day)

QD

0.6 mg/kg/day (up to 40 mg/day)

 

Lisinoprilc

0.07 mg/kg/day (up to 5 mg/day)

QD

0.6 mg/kg/day (up to 40 mg/day)

 

Quinapril

5–10 mg/day

QD

80 mg/day

 

Ramipril

1.6 mg/m2/day

QD

6 mg/m2/day (up to 10 mg/day)

α- and β-adrenergic antagonists

Carvedilolb

0.1 mg/kg/dose (up to 6.25 mg BID)

BID

0.5 mg/kg/dose up to 25 mg BID

 

Labetalolb

2–3 mg/kg/day

BID

10–12 mg/kg/day (up to 1.2 g/day)

β-Adrenergic antagonists

Atenololb

0.5–1 mg/kg/day

QD

2 mg/kg/day up to 100 mg day

 

Bisoprolol/HCTZ

2.5/6.25 mg daily

QD

10/6.25 mg daily

 

Metoprolol

1–2 mg/kg/day

BID

6 mg/kg/day (up to 200 mg/day)

 

Propranololc

1 mg/kg/day

BID – QID

8 mg/kg/day (up to 640 mg/day)

CCBs

Amlodipineb

1–5 y/o: 0.1 mg/kg/day

≥6 y/o: 2.5 mg/day

QD

0.6 mg/kg/day (up to 5 mg/day)

10 mg/day

 

Felodipine

2.5 mg/day

QD

10 mg/day

 

Isradipineb

0.05–0.15 mg/kg/dose

TID – QID

0.6 mg/kg/day up to 10 mg/day

 

Extended-release nifedipine

0.25–0.5 mg/kg/day

QD – BID

3 mg/kg/day (up to 120 mg/day)

Central a-agonist

Clonidineb

5–20 mcg/kg/day

QD – BID

25 mcg/kg/day (up to 0.9 mg/day)

Diuretics

Amiloride

5–10 mg/day

QD

20 mg/day

 

Chlorthalidone

0.3 mg/kg/day

QD

2 mg/kg/day (up to 50 mg/day)

Chlorothiazidec

10 mg/kg/day

BID

30 mg/kg/day (up to 375 mg/day)

 

Furosemidec

0.5–2 mg/kg/dose

QD – BID

6 mg/kg/day

 

HCTZ

0.5–1 mg/kg/day

QD

3 mg/kg/day (up to 37.5 mg/day)

Vasodilators

Hydralazine

0.25 mg/kg/dose

TID – QID

7.5 mg/kg/day (up to 200 mg/day)

 

Minoxidil

0.1–0.2 mg/kg/day

BID – TID

1 mg/kg/day (up to 50 mg/day)

ARA aldosterone receptor antagonist, ARB angiotensin receptor blocker, ACE angiotensin converting enzyme, BID twice daily, CCB calcium channel blocker, HCTZ hydrochlorothiazide, QD once daily, QID four times daily, TID three times daily

aThe maximum recommended adult dose should not be exceeded

bInformation on preparation of a stable extemporaneous suspension is available for these agents

cAvailable as an FDA approved, commercially supplied oral solution

Greater than 50% of adults with HTN will require two or more antihypertensive agents in order to achieve proper BP control [37]. Similar data in children and adolescents are sparse. A single center study suggested that as many as 28% of children are concomitantly prescribed two or more antihypertensive agents for BP control [38]. In this study, addition of hydrochlorothiazide was often employed as the second agent (Table 10).
Table 10

Oral and Intravenous Antihypertensive Medications for Acute Severe HTN

Drug

Class

Dose

Route

Comments

Useful for severely hypertensive patients with life-threatening symptoms

Esmolol

ß-adrenergic blocker

100–500 mcg/kg/min

IV infusion

Very short-acting – Constant infusion preferred May cause profound bradycardia

Hydralazine

Direct vasodilator

0.2–0.6 mg/kg/dose

IV, IM

Should be given q 4 h. when given IV bolus

Labetalol

α- and ß-adrenergic blocker

Bolus: 0.20–1.0 mg/kg/dose, up to 40 mg/dose

Infusion: 0.25–3.0 mg/kg/h.

IV bolus or infusion

Asthma and overt heart failure are relative contraindications

Nicardipine

Calcium channel blocker

Bolus: 30 mcg/kg up to 2 mg/dose

Infusion: 0.5–4 mcg/kg/min

IV bolus or infusion

May cause reflex tachycardia

Sodium Nitroprusside

Direct vasodilator

0.5–10 mcg/kg/min

IV infusion

Monitor cyanide levels with prolonged (>72 h) use or in renal failure; or co-administer with sodium thiosulfate

Useful for severely hypertensive patients with less significant symptoms

Clonidine

Central α-agonist

0.05–0.1 mg/dose, may be repeated up to 0.8 mg total dose

PO

Side effects include dry mouth and drowsiness

Enalaprilat

ACE inhibitor

5–10 mcg/kg/dose up to 1.25 mg/dose

IV bolus

May cause prolonged hypotension and acute renal failure, especially in neonates

Fenoldopam

Dopamine receptor agonist

0.2–0.8 mcg/kg/min

IV infusion

Produced modest reductions in BP in a pediatric clinical trial in patients up to 12 years

Hydralazine

Direct vasodilator

0.25 mg/kg/dose up to 25 mg/dose

PO

Extemporaneous suspension stable for only 1 week

Isradipine

Calcium channel blocker

0.05–0.1 mg/kg/dose up to 5 mg/dose

PO

Stable suspension can be compounded

Minoxidil

Direct vasodilator

0.1–0.2 mg/kg/dose up to 10 mg/dose

PO

Most potent oral vasodilator; long-acting

Treatment of HTN in the inpatient setting includes use of enteral as well as intravenous antihypertensive medications [39]. Classes of medications used for the management of HTN in the intensive care setting include beta-adrenergic receptor blockers, CCBS, and direct vasodilators. Beta blockers such as esmolol, atenolol, and metoprolol demonstrate selectivity for B1-receptors, while propranolol is a non-beta-selective beta blocker. Beta blocker mediated lowering of BP is thought to be mediated via the impact of these agents on the sympathetic nervous system (Klugman D). Hydralazine is a direct-acting vasodilator [40]. Nicardipine is a calcium channel blocker administered by continuous IV infusion in patients with hypertensive emergencies (see below); whereas isradipine is an orally administered CCB that has found use in hospitalized children requiring urgent treatment [41].

Acute Severe HTN

Diagnosis

Acute severe HTN (formerly termed hypertensive crisis or hypertensive urgency/emergency) is now defined as a BP greater than or equal to the 95th percentile +12 mmHg. Acute severe HTN may be complicated by the presence of acute TOD [42]. The most severely affected patients may have symptoms suggestive of hypertensive encephalopathy, including vision changes, headache, stupor, seizure, focal neurologic deficits, and coma [43]. Other manifestations of acute severe HTN may include retinal hemorrhage, papilledema, left ventricular failure, pulmonary edema, hematuria, proteinuria, and azotemia [40].

Potential pathophysiologic mechanisms resulting in acute severe HTN include elevations in BP beyond the capacity of intrinsic autoregulatory processes, leading to transmission of increased pressure to smaller, distal vessels, and thus leading to mechanical stress and vascular wall damage. The endothelium may be damaged by this pressure and as a result there is disruption of the endothelium, increased vascular permeability, cell proliferation, and activation of the coagulation cascade resulting in fibrinoid necrosis of the small arterioles and tissue injury. The renin-angiotensin-aldosterone system is activated, leading to increased angiotensin II (Ang II) release and Ang II-mediated vasoconstriction.

Potential Complications

In some cases, youth with acute severe HTN will develop signs of focal neurologic deficit and develop white-matter changes in the parieto-occipital regions (i.e., posterior leukoencephalopathy) [44, 45]. Other potential complications include stroke, congestive heart failure (CHF), and retinal changes.

Management

Management of acute severe HTN centers on lowering the BP effectively to reduce the risk of further tissue injury; complications that may occur if the BP is lowered too rapidly. Ideally the BP is reduced by 25% of the planned reduction during the first 8 h and then followed by a more gradual reduction in BP over the next 26–48 h [14, 42]. Recommended tests during evaluation for acute severe HTN can be found in in Table 11.
Table 11

Evaluation of Patients with Acute Severe HTN

Eyes

Fundoscopic Examination

Neurologic

Full neurologic examination

To consider CT scan of the head if focal neurologic deficits appreciated

To consider brain MRI: evaluate for edema of the white matter (parieto-occipital regions/posterior leukoencephalopathy)

Cardiac

CXR: if suspect congestive heart failure (CHF)

Echocardiogram: assess left ventricular mass (LVM) and function if suspect CHF

Renal

Electrolytes

Blood urea nitrogen

Creatinine

Complete blood count (CBC) to look for evidence of microangiopathic hemolytic anemia

Other

Females: Pregnancy test

HTN in Infancy

Definitions

BP in infancy varies according to body size, gestational age, and post-conceptual age, among other factors, and few studies have been conducted to develop normative BP data. As a result, in general, there is no generally accepted BP level to define HTN in neonates. Dionne et al. have summarized the scant available data and have proposed BP levels that could be used to define HTN in the infant population [46].

The differential diagnosis of HTN in infancy is wide-ranging and includes: renovascular, renal parenchymal, pulmonary, cardiac, endocrine, medication, neoplastic, and neurologic causes. Investigation of hypertensive infants should proceed in a similar fashion to evaluation in older children with HTN. A thorough review of the infant’s history and a focused physical examination should point to the underlying cause in most cases. Selected laboratory studies should be obtained as indicated. Renal ultrasonography is particularly useful and should always be obtained given the preponderance of renal causes, including thromboembolism, renal artery stenosis (RAS), mid-aortic syndrome, renal venous thrombosis, renal artery compression, multicystic dysplasia, and polycystic kidney disease (PCKD) (Table 12).
Table 12

Differential Diagnosis of HTN in Infancy

Renovascular

Medications/Intoxications

Thromboembolism

 Infant

Renal artery stenosis

  Dexamethasone

Mid-aortic coarctation

  Adrenergic agents

Renal venous thrombosis

  Vitamin D intoxication

Compression of renal artery

  Theophylline

Idiopathic arterial calcification

  Caffeine

Congenital rubella syndrome

  Pancuronium

Renal parenchymal disease

  Phenylephrine

 Congenital

 Maternal

  Polycystic kidney disease

  Cocaine

  Multicystic-dysplastic kidney disease

  Heroin

  Severe renal dysplasia

  Antenatal steroids

  Tuberous sclerosis

Neoplasia

  Ureteropelvic junction obstruction

Wilms tumor

  Unilateral renal hypoplasia

Mesoblastic nephroma

  Congenital nephrotic syndrome

Neuroblastoma

  ACE inhibitor fetopathy

Pheochromocytoma

 Acquired

Chorioangioma

  Acute kidney injury

Neurologic

  Cortical necrosis

Pain

  Interstitial nephritis

Intracranial HTN

  Hemolytic-uremic syndrome

Seizures

  Obstruction (stones, tumors)

Familial dysautonomia

Pulmonary

Subdural hematoma

Bronchopulmonary dysplasia

Other causes

Pneumothorax

Volume overload

Cardiac

Closure of abdominal wall defect

Aortic coarctation

Adrenal hemorrhage

Endocrine

Hypercalcemia

Congenital adrenal hyperplasia

Traction

Hyperaldosteronism

Extracorporeal membrane oxygenation

Hyperthyroidism

Birth asphyxia

Pseudohypoaldosteronism type II

 

Glucocorticoid remediable aldosteronism

 

HTN in the Intensive Care Unit (ICU)

HTN in the ICU may arise for a variety of causes that include primary versus secondary diagnoses. HTN may develop secondary to medications received, underlying conditions and pain. Intra-arterial BP assessment is the most direct method for assessing BP in the ICU. In absence of an intra-arterial line, oscillometric BP assessment may be utilized. Manual BPs are rarely available.

Children with persistent HTN may require IV or enteral antihypertensive therapies. See above discussion of “Acute Severe HTN.”

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Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2020

Authors and Affiliations

  1. 1.Nemours-Alfred I. DuPont Hospital for ChildrenWilmingtonUSA
  2. 2.University of WashingtonSeattleUSA
  3. 3.Division of NephrologySeattle Children’s HospitalSeattleUSA

Section editors and affiliations

  • Stephen R. Daniels
    • 1
  1. 1.Department of PediatricsUniversity of Colorado School of Medicine and Children’s Hospital ColoradoAuroraUSA

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